This short piece addresses the challenges of being biracial and finding your own voice while listening to the conflicting voices of others: parents, grandparents, friends, mentors, teachers, coaches. I had two constraints while writing this: one, I had to emulate Jamaica Kincaid’s short story “Girl,” where a mother teaches her daughter how to be a respectable girl and not “the slut you are so bent on becoming”; and two, I had to develop this for a high school literature assignment while studying remotely during New York’s pandemic lockdown. I had no “in-person” communication other than with my immediate family, which made it even harder to find one’s own voice: you need the voices of others in order to distinguish yours from theirs. I wondered: what is sound--music? vibrations? noise? everyday sounds? silence? Will silence always protect you?

ABSTRACT: History of present illness: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presented to the emergency department with stabbing chest pain to the right lower rib region along the axillary line. On examination, patient had no visible trauma, but was in mild respiratory distress with absent breath sounds on the right side. The patient's oxygen saturation ranged in the 90s on room air during his encounter, but otherwise had unremarkable vital signs.

Significant findings: The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb.

A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax.

Discussion: Pulmonary blebs are collections of air in the alveolar layer of the pleura formed by a rupture of the alveolar wall.1 They can leak air into chest cavity leading to a high rate of recurrent spontaneous pneumothorax.2 Chest X-rays (CXR) are the current gold standard in diagnosing pneumothorax. A recent study among 192 critically ill patients showed CXR has high diagnostic accuracy and positive predictive value, at 90.6% and 95.0%, respectively.3 Visible visceral pleural lines on CXR seen without distal lung markings is usually diagnostic of pneumothorax.4 In this case however, the patient’s CXR and lung ultrasound findings were similar to standard pneumothorax findings, however chart review demonstrated the patient had a known large pulmonary bleb.

The treatment for pneumothorax is chest tube insertion. To avoid unnecessary chest tube placement, emergency physicians must consider pulmonary blebs as a diagnosis in patients with mild respiratory distress who have a large area of absent lung parenchyma and visible visceral pleural lines on CXR. If a clinician is unsure and does not have access to previous imaging, a computed tomography scan of the chest can be used to clarify the diagnosis.5

This patient was conservatively managed with oral prednisone, intravenous morphine sulfate, combination albuterol-ipratropium nebulizer treatment, and later discharged for pulmonology follow up.6 The patient did not require any further imaging during this visit. In recurrent disease or severe dyspnea, bullectomy may be indicated.

Topics: Ultrasound, X-ray, pulmonary blebs, pneumothorax.

Learning Objectives: Our initiative aims to develop an education innovation that contributes to: • Enhancing EHR usability through facilitating the process of placing medical orders. • Decreasing click fatigue while increasing professional satisfaction among emergency medicine residents.

Introduction/Background: Bureaucratic tasks are the leading cause of burnout among emergency medicine physicians. Among those tasks is placing medical orders in the Electronic Health Record (EHR), which is a time-consuming and rigorous process that can lead to click fatigue and increase physician burnout. Therefore, we believe that optimizing the EHR experience for order placement will not only decrease the amount of time spent using the EHR but will also decrease click fatigue and improve overall satisfaction of emergency medicine physicians.

Curricular Design: We designed a PowerPoint educational module for the emergency medicine residents that guides them through the process of creating their own personalized order sets. In this module, we demonstrated the step-by-step process of developing order sets for three of the more common presentations to the ED: chest pain, abdominal pain, and headache. This is a significant, minimal cost method that can be used to facilitate many patient encounters through expediting the placement of workup and management orders. After partaking in the educational module, residents were able to develop their own personalized order sets, which will inevitably reduce the number of clicks.

Impact/Effectiveness: Integration of this module has been successful among the emergency medicine residents and was very well received. The number of clicks saved using the order sets presented in the PowerPoint educational module was eight, six, and fifteen clicks for the chest pain, abdominal pain, and headache order sets, respectively. This educational innovation has high transferability to other institutions that use EHRs. We expect that employing this strategy will decrease the amount of time spent on bureaucratic tasks, decrease click fatigue, and improve the overall wellness of the ED physician. Our long-term plan includes expanding our educational curriculum and utilizing qualitative assessment tools to examine its effectiveness.